Medication safety

This page is part of the wider ‘enduring standards that remain valid from previous patient safety alerts‘ set of webpages.

Medication-related incidents remain one of the most frequently reported categories of patient safety incidents, accounting for about 10% of reported incidents. National organisations such as the Royal Pharmaceutical Society (RPS), Specialist Pharmacy Service (SPS), Medicines and Healthcare products Regulatory Agency (MHRA) and other regulatory bodies provide a wide range of resources that support safe medication practice, some developed in response to past alerts.

The Medicines Safety Improvement Programme oversees quality improvement work in several key medication safety areas, including safer use of anticoagulants, problematic polypharmacy, and safer administration of medicines in care homes. Within this broader context, the enduring standards set out in previous alerts should remain an important part of every organisation’s medication safety strategy.

Identification of medication safety officers

The enduring standard from past alerts that remain valid is:

Access to antidotes/reversal agents

Enduring standards from past alerts that remain valid are:

However, access to appropriate antidotes/reversal agents is a principle that applies to other medications administered within healthcare, and organisations should consider these enduring standards in the wider context of supporting access to all antidotes/reversal agents their service requires, alongside supporting their safe and appropriate use.

Safe administration

Enduring standards from past alerts that remain valid are:

Safe administration of medicines is clearly a much wider overarching principle; guidance and improvement resources produced by national organisations should be consulted including the RPS/Royal College of Nursing (RCN) professional guidance on the administration of medicines in healthcare settings.

Safe storage of medicines

Enduring standards from past alerts that remain valid are:

However, the principles of restricting access to medications that might be mis-selected apply to all medications administered within healthcare, and organisations should consider these enduring standards in the wider context of restricted access and best practice in design and layout of storage of medication to reduce mis-selection errors. Guidance and improvement resources produced by national organisations should be consulted, including the RPS guidance on safe and secure handling of medicines.

Safe prescribing practice

Enduring standards from past alerts that remain valid are:

Two medicines that were the focus of safe prescribing guidance in past alerts have had a continued multi-agency focus with new advice that has superseded previously issued alerts:

  • methotrexate: MHRA guidance supersedes the previously issued alert
  • valproate: a Valproate Safety Implementation Group has been established and will provide guidance that supersedes the previously issued alert. Organisations should implement this guidance as soon as it is published.

The principles of safe prescribing apply to all medications prescribed within healthcare, and the enduring standards described above can be applied to other medicines (eg using ‘units’ when prescribing heparin and other medicines) or clinical situations. Organisations should consider these enduring standards in the wider context of guidance from national organisations including good prescribing practice, the need for continuity of presentation, and awareness of regulatory restrictions for certain medicines; including the need to ensure pregnancy checks and pregnancy prevention plans for all types of medications where teratogenic effects require this.

Medication (including infusion) labelling

Enduring standards from past alerts that remain valid are:

However, principles for medication labelling apply to all medications purchased, manufactured, and dispensed within healthcare. Organisations should consider these enduring standards in the wider context of best practice guidance on the labelling of medicines; including the information that is critical for the safe use of medicines, and the format and style of the information provided, to avoid confusion between look alike, sound alike (LASA) medicines.

 

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